CANADA

PROVINCE OF NOVA SCOTIA

HALIFAX REGIONAL MUNICIPALITY

IN THE SUPREME COURT OF NOVA SCOTIA

HER MAJESTY THE QUEEN

-AND -

AFFIDAVIT

I,

make oath and say as follows;

                                                                                        _______________________________

Sworn to at Halifax, in the

County of Halifax, Province

of Nova Scotia this _____ day

of ___________, A.D. 20____

_____________________________